Carcinoma of Thyroid and Their Diagnosis

Pandey, P., Yadav V.C. John Masih, Azad K.L., Shrivastav P.K.

Govt. Medical College, Jagdalpur, Bastar (C.G.) 494001 INDIA.

ABSTRACT:

Back ground: Cancer accounted for 5 lakh death in India alone in 2005 .More than two thirds of all cancer deaths occur in low and middle income countries. Objective: To assess the techniques of fine needle aspiration cytology and Imprint cytodiagnosis in thyroid cancers. Study designs: four patients of thyroid lumps, attending O.P.D. of Hamidia, hospital, Bhopal were selected for the study. Convenient sampling was done .Patient’s detailed history, routine and special investigations as per need were carried out. Statistical analysis: The analysis of data was done with the help of manual tabulation and for calculation of percentages. Results: FNAC-The accuracy rate was 75 percent while in imprint cytodiagnosis an 100 percent accuracy rate was noticed. Conclusion: The authors reached to the conclusion that F.N.A.C. save time, resources and patient anxiety. Admission for operation can be properly timed and the chances of missing thyroid cancers are much reduced. As there is paucity of data of imprint cytodiagnosis and in the present study too the sample was small so more study is to be done for getting comprehensive picture of the disease.

KEYWORDS: Radioactive Iodine, Safety norms, Third hand smoking

INTRODUCTION:

Goiters are common and their informed management is be set by two major difficulties, firstly although accessible to palpation, clinical examination is modest in its accuracy. Some 60% of thyroid cancers are reported to present as a benign lesion, Einhorn and Franzen, in 1962. Apparently solitary nodules are found at operation to arise within a multimodal goiter. Also 20 % of patients with Hashimoto’s disease may elude detection, Bain and Crockford in1978 especially where the goiter is unilateral and the auto-immune process develops within a preexisting nodular goiter. Such cases may closely simulate carcinoma Doniach in 1978. Secondly, standard thyroid investigations including A and B mode ultrasonography and scintiscanning are not precise enough to indicate a firm preoperative diagnosis, Greene et. al. in 1964 and reliably differentiate benign from malignant nodules, within this context the aim of F.N.A.C. which is particularly safe in such a vascular organ as the thyroid is to contribute to precise management in the following ways.

1. The recognition of the thyroidities, which in many instances is more suited to thyroxin therapy or as in De Quatrain’s disease a period of observation. Surgery has a restricted application.

2. To avoid surgery in a clinical nodular goiter which does not carry a pressing need for surgery reassured by a firm tissue diagnosis.

3. To establish the presence of poorly differentiated carcinoma and lymphoma for which surgery has very limited indication and where radiotherapy and / or chemotherapy is preferred.

To discover papillary and medullar carcinoma: also follicular neoplasms and attempt to differentiate between adenoma and carcinoma. Surgical intervention may therefore be precise and avoid the risks from preoperative excision biopsy.

For papillary carcinoma a detailed search for nodes will be necessary and for medullar carcinoma, a total thyroidectomy and possibly implantation of the parathyroid glands.

An estimated 1.4 million to 2 million people experienced catastrophic spending in 2004 with 6-8 lakh Indians ending up being impoverished by the cost of caring for cardiovascular and “cancer” alone .Global focus firmly on diseases like cancer etc. and will receive both time and money. Cancer ranked third in Non Communicable Diseases as cause of death (1).By keeping in mind the above facts and in 1957 a study group of World Health Organization (W.H.O.) has expressed the view that in order to get a comprehensive picture of disease (health problem) more and more such studies have to be carried out, Garg Narendra K. (2). This prompted the authors to undertake this study to asses the efficacy of the diagnostic accuracy of fine needle aspiration cytodiagnosis and imprint cytodiagnosis in thyroid cancer.

MATERIALS AND METHODS:

Four patients of Goiter attending the Surgical O.P.D. of a Medical College Hospital were taken as sample for this study. All four cases subjected to detailed history and findings of the physical and clinical examination were recorded in a pre drawn proforma. Routine and special investigations as per requirement were done. Having thus made a clinical diagnosis, the lumps were subjected to fine needle aspiration cytology, excision then imprint smears were obtained and specimen subjected to Histological examination.

Materials:

1. 20 ml. disposable syringe.

2. 22 or 23 f. gauge disposable needle.

3. Albumenized glass slide.

4. Ajar containing 95 percent Ethyl Alcohol.

5. Diamond Pencil.

TECHNIQUE: The skin is cleaned with antiseptic and accompanied by a suitable “patter” to reassure and distract the patient –the needle is delicately inserted in to the lesion by an oblique track perceiving the tissue texture on entry and penetration. Constant suction is now required to ensure an adequate yield .With suction in play, the needle is gently passed through the lesion in three or four directions .The suction is gently released and the needle withdrawn .Pressure is exerted over the puncture site with a cotton wool “ball”. The needle having been detached from the syringe, air is drawn back in to the syringe and the contents of the needle bore are blown on to dry clean 97.5 x 2.5 cm. 3 x 1 cm.) in microscope slides (albumenized ).

Method for naked eye examination: Palpation, section, re palpation, and inspection in that order be performed as the best routine for naked eye examination of freshly removed lump.

Palpation is most important since carcinoma is almost without exception uniquely hard, the only lesion to feel as hard as cancer is a thick walled cyst and this becomes obvious after section when hard ness disappears

Inspection after cutting the lump often helped in diagnosis of the type of Tumour concerned. The tabulated rather friable whorled appearance of the fibro adenoma is mistakenly clear and retracted, gritty.’Raw pear” appearance of the schirrous carcinoma is also usually diagnostic .The better delineated, grayer, protruding medullar carcinoma can usually be distinguished from other malignant tumors.

Figure: 01 Case of Thyroidities

In general malignant lesions were harder, cut like a un ripe pear and gritty to feel and cut surface were concave, while benign were soft to firm, easy to cut and cut surface are usually convex when it is solid.

Naked eye examination of imprint can give some clue to final diagnosis. The imprints are more cellular and uniform ad occupied area on the slide, while Benign imprint were less c3llular with an exception to fibroadenoma, they are scatted over the slide and less uniform cells are more towards periphery and on staining they were looking less dark as compared with malignant.

Equipments:

1. Clean albumenized glass, numbered by diamond pencil.

2. Paper clips to keep the slides separate from each other while fixing it.

3. Coupling jars.

4. 95% Ethyl alcohol.

5. Cover Slips

6. 10% aqueous formalin for fixation of tissue for paraffine block.

Procedure:

After surgical removal, the lump was thoroughly inspected and palpated first as such. A diagnosis, being it benign or malignant, was recorded. Then theimprent were prepared according to the technique described by TRIBE. The excised lump was bisected into two to give a freshly cut surface. After taking a portion of growth from the representative area for paraffin section adjacent portion of the tissue was trimmed to approximately one cm. in diameter. The tissue is then held between the fingertips and pressed firmly on to a clear albumenized microscopic slide held in the other hand. It was essential that there should be no lateral or sliding movement. As soon as imprint was obtained the slide was immediately fixed by 95% alcohol for half hours and routinely two imprints were made from each specimen. The same piece of tissue was immediately put into 10% Aqueous solution of formaldehyde and submitted for paraffin block preparation.

Precaution:

1. The tissue sample to be imprint should be flat and there should be no portion of fat protruding from the edges as these tend to smudge the imprint.

2. Sometime the first imprint contains excess tissue fluids and blood. It will be found that the subsequent imprint give better cytological results.

3. There should be no lateral or sliding movement of the tissue when imprinting on the slides.

4. The malignant tumour usually imprint more easily than benign lesions. Therefore, benign looking lesion especially requires very firm pressure in order to obtain sufficient cell for diagnosis.

5. Slides should remain in fixative for atleast 20 to 30 minute before staining with modified papaniculaou technique.

OBSERVATIONS:

On analysis of the collected data it has been revealed that 75% cases were benign and the remaining 25% malignant. On F.N.A.C. 75 % cases could be diagnosed correctly and the remaining 25 % were false negative and not a single case was diagnosed false positive. Thus giving the correctly diagnosed accuracy rate of 75 % (Table –I).

Regarding Imprint cytodiagnosis all 100 % cases were correctly diagnosed. Thus giving the accuracy rate of 100 % in comparison to 75 % by F.N.A.C.

DISCUSSIONS:

In the present study an accuracy rate of 75 % and 100 % were observed by F.N.A.C. and Imprint cytodiagnosis respectively.

Near similar results have been observed by Einhorn and Franzen in 1962, Gerstengen in 1977 and Wolfish in 1977 (Table – II).

Einhorn and Franzen in 1962 studied 177 cases of goiter by F.N.A.C. and yielded an accuracy rate of 92% and 8% false negative.

Gerstengen in 1977 studied 33 cases of goiter and gave an accuracy of 94% with 3% false positive and 3% false negative.

Wolfish in 1977 studied 86 cases of goiter and gave an accuracy rate of 95%. In the present study accuracy rate was 75 % which was lower then the findings of other studies which may be because of the low sample size.

Imprint: There is paucity of literature on imprint of thyroid tissue. Our series has too few cases of goiter to have any impact in spite of 100% accuracy shown.

Within the group of 180 nodular goiters, three were suspected to be a follicular adenoma and six other yielded a typical cytology. A current authoritative view Lowhagen et.al.in1970 holds that cytology cannot reliably distinguish benign from malignant follicular lesions. The overall accuracy for follicular neoplasms is 90%.

There have been no serious difficulties in the identification of Hashimoto’s disease but false positive reports are recorded by Chu et. al. in 1979. It must be admitted that certain aspect of thyroid cytology are difficult and important problems in diagnosis may be summarized under the following group:

1. The distinction between a true follicular adenoma and adenomatous change within a nodular goiter can be slight and the criteria in the Armed Forces Institute of Pathology Fascicle Meissner and Warren, in1969 are by no means absolute.

2. The state of the remainder of the thyroid is very relevant to the opinion of some histopathologist, yet it may be difficult for the surgeon to detect a minor degree of nodular change.

3. Despite a macroscopically operative appearance of multinodularity it may still be possible for a nodule to be follicular neoplasm.

4. Cystic neoplasm’s from which fluid is aspirated closely mimic colloid nodules .Heavily blood stained cellular smears would arouse the suspicion of malignant origin but in all cases repeat smears and careful examination of the whole smear is essential.

5. The cellular of colloid and hyperplasic nodules varies considerably and extremely atypical cells of uncertain origin may be seen.

6. The cells from some well differentiated papillary and follicular carcinoma show little variation from a hyperplasic colloidal nodule. If the site of aspiration is non thyroid lymphoid or bone, then the clinical diagnosis is made but the cytology remains disconcerting.

7. The recognition of Hashimoto’s disease within a nodular goiter can be perplexing if polymorphic Askenazy cells without a lymphoid component is aspirated. The auto immune profile may be unhelpful as with this type of thyroiditis the serum changes are slow in development .If there is any clinical uncertainty regarding the thyroid then thyroidectomy is strongly indicated.

There is a need for further clinical and cytological research in the diagnosis of Goiters.

Thyroid patients get beta rays of hope Radiation route to better health (5) Radioactive Iodine is used for hyperthyroidism, where an operative thyroid gland secretes more hormone than required, causing problems in the body. After surgery for thyroid cancer, where the gland is removed surgically, but cancerous parts may be left in the body.

How it works: The thyroid gland accumulates Iodine and uses it to produce thyroid hormones required for normal bodily functions. When radioactive Iodine is taken in the body, it is absorbed by the stomach and intestines and carried in the blood stream to the Thyroid. In the Thyroid, the iodine disrupts the function of of some thyroid cells, so an overactive thyroid is curved.

Administrating the dose –The radioactive iodine is put in a vial kept in a hume hood. The hood is a vacuum shielded by lead on all sides. The patient put their head in the hood and drinks the Iodine through a straw. A suction pump ensures that spilled iodine is safely collected.

Hyperthyroid patients get a low dose and are sent home in 5 minutes .Thyroid cancer patients get a higher dose and are put in isolated rooms. The patients and staff are checked for radioactivity .Empty vials etc are disposed of properly.

Generally, people are scarred to carry radioactivity around. Patients need counselling about the risks and advantages. Patients ,persons around them, the community and the service providers all should be make aware about the safety norms (6,7,8,) . Safety Norms (i) A small amount of Gamma radiations will emanate from the patient for a few days after treatment. While this radiation is beneficial to the patient, precautions are needed to reduce the radiation; the family and friends are exposed to. (ii) Avoid prolonged contact, especially with babies and pregnant women. (iii) Drink a lot of water. (iv) Keep clothes and utensils away from the people. (v) Avoid pregnancy of breast feeding.

Dr. Ramesh Asopa, head of clinical nuclear medicine, Radioactive Medicine Centre (R.M.C.), The Bhabha Atomic Research Centre said that not everyone is subjected to radioactive Treatment. “Radioactivity can work in only certain conditions. For hyperthyroidism ,the patient is first given clinical medicines for six months .If that does not work, then tests and scans are done, which tell how much radioactivity’s to be administered, if at all “.

Does imprint cytology obviate frozen section histology? Is almost 100 percent reliable. Halady et. al. reported an error on frozen section examination of 1.5 (3 percent).

Frozen section histology (4) for different tissues, there was 1 false positive in 1063 examination of breast tissues. Figures vary from 0 to 0.15 percent false positives. False negative reports in frozen section are eight times more common then false positives with figures ranging from 1.3 to 3 percent.

In the present study accuracy rate of imprint cytolodiagnosis is 100 percent with no false positive and false negative (sample size was very small).

It is apparent that imprint cytology can very effectively and economically replace frozen section as a method of intra-operative diagnosis

There must be no false positive diagnosis of cancer if cytology is to be reliable method of diagnosing carcinoma. This demands considerably restriction and stringent criterion for diagnosis of cancer. For a definite statement cells must be unmistakenly malignant. Any method of preoperative diagnosis must be entirely reliable and also provide a diagnosis in enough patients to achieve its objective.

Third –hand smoke can cause cancer too: People at risk from tobacco residue on surfaces, a US study say third hand smoke –tobacco residue clinging to surfaces is also bad and can cause cancer (6).

Researcher reported that they found cancer-causing agents called tobacco specific nitros –amines stick to a variety of surfaces ,where they can get in to dust or be picked up on the fingers .Children and infants are the most likely to pick them up ,the team at Lawrence Berkely Laboratory at California reported.

These findings raise concerns about exposure tos to the tobacco smoke residue that has been recently dubbed “third-hand smoke”, the researcher wrote in the Proceedings of the National Academy of Sciences.

They suggested a good clean up could help remove these potentially harmful chemicals and said their findings suggest other air borne toxins may also be found on surfaces. TSNAs (tobacco specific nitrosaminases) are among the most broadly acting and potent carcinogens presents in unburn tobacco and tobacco smoke “Barkely chemist Hugo Destaillats, who worked on the study, said.

TABLE – I. GOITER CASES

Investigation		Cases Correctly Diagnosis	False Diagnosis
			Negative	Positive
F.N.A.C.	Benign n = 03	03 (100.0)	-	-
	Malignant n = 01	00 (00.0)	01 (100.0)	-
Imprint cytodiagnosis	Benign n = 03	03 (100.0)	00 (00.0)	00 (00.0)
	Malignant n = 01	01 (100.0)	00 (00.0)	00 (00.0)

Figures in parenthesis indicate percentage.

TABLE – II. FINDINGS OF DIFFERENT AUTHORS AND PRESENT STUDY F.N.A.C. IN THYROID CANCER

S. N.	Author(s)	Year	Total No. of Biopsies	No. of Correct Diagnosis	False Positive	False Negative	Percentage of Correlation
1.	Einhorn and Franzen	1962	177	167 (94.35)	06 (03.38)	04 (2.25)	94.0
2.	Garshengen	1977	33	30 (93.93)	01 (03.03)	01 (03.03)	94.0
3.	Wolfish	1977	90	86 (95.55)	01 (01.1)	00 (03.33)	95.0
4.	Present series	1990	04	03 (75.0)	00 (00.0)	01 (25.0)	75.0

Figures in parenthesis indicate percentage.

“The burning of tobacco releases nicotine in the form of vapor that absorbs strongly onto indoor surfaces, such as walls, floors carpetting, drapes and furniture .Nicotine can persist on those materials for days ,weeks and even months”

The nicotine combines with another common compound called nitrous acid to form tobacco specific Nitrosaminase or TSNAs, Destaillats and colleagues found. Unvented gas appliances are the main source of nitrous acid indoors, and vehicles engines emit too.

For early diagnosis and prompt treatment intensified Information, Education and Communication (I.E.C.) drive will have to be carried out. Media like Television, Radio, Print media, and Local media eg. folk dances and folk songs which is suited to the local culture and customs is to be exploited in favour of bringing awareness in the masses (7,8,9,&10).

ACKNOWLEDGEMENT:

The authors express their cordial thanks to to Dr. A.K. Bansal, Ex-Professor &HOD, Dept. of Community Medicine, Govt. Medical College, Jagdalpur (C.G.) for his support and valuable guidance for the study..

REFERENCES:

1. Non – communicable diseases drained India of $ 9 bn in 2005: The Times of India, New Delhi ;30.4.2011 :pp 7.

2. Garg Narendra K. Evaluation of the impact of emesis and emesis plus purgation therapy; Research J. Pharmacology and Pharmacodynamics: 2 (2) March – April 2010; 201-202.

3. Webb A. J.: Surgical aspects of aspiration biopsy Cytology; Recent advances in Surgery; 1983:vol.11:39.

4. Heilpap B. et al: Comparison between frozen section histology and imprint cytology of breast biopsies; Forth .Med; 1977:95; 35; 2119-2120.

5. Thyroid patients get beta rays of hope: The Times of India, New Delhi; Thursday, May 27, 2010.

6. Third-hand smoke can cause cancer too: The Times of India, New Delhi, Thursday, February 11, 2010; pp 16.

7. Bansal A.K. Chandorkar R.K., Knowledge, Belief, and Practice: A study of Tribal Mother about feeding of infants, Tribal Health Bulletin (I.C.M.R.) 1993; 2:3-4.

8. Garg Narendra K. and Bansal A.K. Management of information system in context of health care delivery .J of Ravishanker University; Vol 14:No. B (Science) 2001:35-40.

9. Bansal A.K and Garg Narendra K, Information, Education, Communication in context oh reproductive and child health including HIV/AIDS. J. of Ravi Shanker University; Vol 14 No. B (Science) 2001:28-34.

10. Alfia Fatima, Bansal A.K., Shamsuddoha, Ratre, H.L. et. al. Leprosy elimination in district Sarguja ;J of Ravishankar University :Vol.18 :No. B (Science) 2006; pp 61-68.

Received on 05.06.2011

Modified on 18.07.2011

Accepted on 12.08.2011

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Research J. Science and Tech. 4(1): Jan.-Feb. 2012: 40-44